McGarry, Julie (2017) Domestic violence and abuse: an exploration and evaluation of a domestic abuse nurse specialist role in acute health care services. Journal of Clinical Nursing, 26 (15-16). pp. 2266-2273. ISSN 0962-1067
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Title: Domestic violence and abuse: an exploration and evaluation of a
domestic abuse nurse specialist role in acute health care services
Author details: Dr Julie McGarry, DHSci, MMedSci, BA (Hon), RN (adult
and mental health) Associate Professor, School of Health Sciences,
University of Nottingham, A Floor Queens Medical Centre, Derby Road,
Nottingham NG7 2HA, UK Tel: 0044+(0)115 82 30516
Email: [email protected]
Acknowledgements and funding: Thank you to all of those who agreed to take
part in the study. Thank you to Nottingham Hospitals Charity for funding
support.
2
Abstract
Aims and objectives The aim of the present study was to explore the
experiences of clinical staff in responding to disclosure of domestic
violence and abuse (DVA) and to evaluate the effectiveness of training
and support provided by a dedicated Domestic Abuse Nurse Specialist
across one acute National Health Service (NHS) Trust in the UK.
Background The impact of DVA is well documented and is far reaching.
Health care professionals have a key role to play in the effective
identification and management of abuse across a range of settings.
However there is a paucity of evidence regarding the constituents of
effective support for practitioners within wider non-emergency hospital
based services.
Design A qualitative approach semi-structured interviews (n=11) with
clinical staff based in one acute care Trust in the UK. Interviews were
informed by an interview guide and analysed using the Framework
approach.
Findings The organisation of the NS role facilitated a more cohesive
approach to management at an organisational level with training and
ongoing support identified as key facets of the role by practitioners. Time
constraints were apparent in terms of staff training and this raises
questions with regard to the status continuing professional development
around DVA.
3
Conclusions DVA continues to exert a significant and detrimental impact
on the lives and health of those who encounter abuse. Health care
services in the UK and globally are increasingly on the frontline in terms
of identification and management of DVA. This is coupled with the
growing recognition of the need for adequate support structures to be in
place to facilitate practitioners in providing effective care for survivors of
DVA.
Relevance to clinical practice This study provides an approach to the
expansion of existing models and one which has the potential for further
exploration and application in similar settings.
Keywords domestic violence and abuse, health care professionals,
training, management
Summary box
What does the paper contribute to the global clinical community?
Raising awareness of the breadth and scope for presentations of
DVA within non-emergency hospital settings
Demonstration of the effectiveness of a specialist role and model for
service development in the effective support and management of
DVA within health care settings
Potential for future development and implementation of the role and
model presented in this paper in other hospital/healthcare settings
institutions and organisations
4
INTRODUCTION
It is now widely acknowledged that domestic violence and abuse (DVA) is
a significant global health and societal concern (World Health
Organisation, WHO, 2015). It is also recognised that DVA impacts
significantly on both short and long term physical and mental health ill-
health and wellbeing of those who experience abuse (Feder, et al. 2011,
McGarry, et al. 2011, Trevillian, et al. 2012).
In the United Kingdom (UK) a number of key national policy directives, for
example the National Institute for Health and Care Excellence (NICE,
2014) Domestic violence and abuse: how health services, social care and
the organisations they work with can respond effectively have clearly
identified that all health care professionals and the agencies they work
alongside have a central role to play in the prevention and effective
management of DVA presentations.
However, to date while there has been an increasing onus on the role of
health care professionals in terms of effectively supporting survivors of
DVA, it is less clear how this should be institutionally organised (Garcia-
Moreno, et al. 2015) or operationalised in practice (Leppakoski, et al.
2014).
Moreover, with a few limited exceptions the majority of exploration to
date has occurred within a few specific health care settings for example,
emergency services and primary care or where routine enquiry into DVA
forms a part of everyday practice (Ellsberg, et al. 2015).
5
BACKGROUND
Within the United Kingdom (UK) and globally DVA is now actively
recognised as a significant societal and public health issue (WHO, 2015).
Due to a number of factors including under reporting, prevalence figures
for DVA are likely to be conservative. However, the World Health
Organisation (WHO, 2015) has recently reported that approximately 30%
of women worldwide have experienced physical or sexual violence from a
partner. Within the UK it has been estimated that approximately 1.2
million women and 700,000 men have experienced DVA, while every
month 7 women are killed by their partner or ex-partner in England and
Wales (Office of National Statistics, (ONS) 2015).
The impact of DVA on the lives and health of those affected is now well
documented and is recognised as potentially far reaching. In a recent
review of the literature for example Dillon et al. (2012) identified that the
effect on physical health may include chronic pain, bone and muscle
conditions, gynaecology or gastro-intestinal problems, while the
consequences for mental health can include poor self-perceived mental
health, anxiety and depression and self-harm. DVA also exerts a
considerable detrimental impact on the wider family, including children
(Hester, 2011) and can continue to exert a detrimental impact on health
and wellbeing in later life (McGarry, et al. 2011).
However, Bradbury-Jones et al. (2014) have argued that while health
care services “play a central role in recognising and responding to
6
domestic abuse, there is a double-edged problem” (p3058) in that health
care professionals are reluctant to approach the subject of DVA with
patients/clients and are equally ill equipped to respond appropriately to
disclosure.
In the UK, there have been a number of recent key legislative and policy
changes which have served to both develop an understanding of the
complexity and breadth of contemporary DVA and to set out core
professional responsibilities.
In 2013, in recognition of the complexity of DVA, the UK Home Office
revised the formal definition of DVA and encompasses the following:
Any incident or pattern of incidents of controlling, coercive or threatening
behaviour, violence or abuse between those aged 16 or over who are or
have been intimate partners or family members regardless of gender or
sexuality. This can encompass but is not limited to […] psychological,
physical, sexual, financial [and] emotional [abuse].
This definition […] includes so called ‘honour’ based violence, female
genital mutilation (FGM) [cutting] and forced marriage, and is clear that
victims are not confined to one gender or ethnic group (Home Office,
2013).
While the National Institute for Health and Care Excellence (2014) Report
Domestic violence and abuse: how health services, social care and the
organisations they work with can respond effectively highlighted the
pivotal role of health services in the effective recognition and
7
management of DVA and also set out a series of broad recommendations
with regard to the provision of professional education and training (NICE,
2014).
It was against this backdrop of emergent national UK policy, growing
recognition of the pivotal role of health services in supporting individuals
who have experienced domestic abuse and the continued uncertainty
regarding the constituents of effective support that one NHS Hospital
Trust in the UK developed a Trust wide domestic abuse nurse specialist
role. At inception it was envisaged that this role would focus on all clinical
areas within the Trust (both in-patient and out-patient) with the exception
of the emergency Department (ED), midwifery and children’s services
where domestic abuse services and specialist practitioner roles were
already in place. The impetus for the development of the trust wide role
was based in part on the preceding local evaluation of the ED nurse
specialist role and the recognition that there were potential gaps in
existing service provision. For example, where patients did not disclose
while in the ED but later disclosed their abuse following admission to in-
patient settings.
From a strategic perspective, it was envisaged that the nurse specialist
role would be situated within a wider intra and inter professional
framework thereby enabling a collaborative or ‘joined-up’ approach to
DVA management both within the Trust and through other appropriate
agencies for example, specialist agencies.
8
Utilizing the success of the ED nurse specialist post as a template (author,
et al. 2013), the remit of the Trust wide nurse specialist role, which has
been described in detail elsewhere (author, et al. 2014) encapsulated the
following:
On-going support and guidance for clinical staff in identification,
referral and resources
Support for survivors of abuse, including referral and signposting to
resources
Liaison and supportive working with specialist DVA nurses in other
areas of the Trust
Liaison and supportive working with other agencies, for example
multi-agency specialist DVA services
The delivery and evaluation of targeted education and training
STUDY AIM
As this was a novel role the aim of the present study was to explore the
experiences of clinical staff in responding to disclosure of DVA and to
evaluate the effectiveness of training and support provided by a dedicated
Domestic Abuse Nurse Specialist (NS) across one acute National Health
Service (NHS) Trust in the UK.
9
METHODS
Design
A qualitative approach using semi-structured interviews with clinical staff
based in one acute care Trust in the UK. Interviews were informed by a
pre-piloted interview guide and analysed using the Framework approach
(Ritchie & Lewis, 2003). Interview data were collected between November
2014 and March 2015.
Setting and participants
The study was undertaken in one NHS Hospital Trust which offers a range
of in-patient, out-patient, emergency and specialist services in one region
of the UK.
In total eleven members of staff agreed to take part in an interview
(Table 1). All of those who participated in the interviews held clinical roles
within the organisation. The time held in their current roles ranged from 6
months to 30 years. All participants were female. Recruitment to the
study was initially undertaken during the DVA training sessions where
study information sheets were distributed to attendees and potential
participants were able to return a tear-off slip with contact details in a
pre-addressed envelope to the study lead (author) to discuss further if
they were interested in taking part in a semi-structured interview.
10
Data collection
Semi-structured interviews were used to collect data and were carried out
with clinical staff at a time and location convenient to them. A pre-piloted
interview guide was used to explore participant’s experiences of
disclosure of DVA and views of the domestic abuse nurse specialist role
(NS), the training sessions and how they had used the training to inform
their responses to DVA within their own practice. With participants
permission all of the interviews were audio-recorded and transcribed
verbatim. Typically the duration of interviews was 60 minutes.
Data analysis
Data analysis was informed by The Analytic Framework (Ritchie & Lewis,
2003) which has five key stages; generating themes and concepts,
assigning meaning, assigning data to themes/, concepts to portray
meaning, refining and distilling more abstract concepts, assigning data to
refined concepts to portray meaning. During the study data collection and
analysis was iterative. In practice this meant that emerging themes from
interviews were pursued in subsequent interviews. A thematic table was
developed to organise data and the emerging themes.
Ethical approval
Using the UK Health Research Authority Decision Tool the study was
defined as a service evaluation and full ethical approval was not required.
However, a formal study protocol was submitted and appropriate
permissions were sought and granted by the (NHS) Trust Research and
11
Clinical Governance Office where the study was undertaken. The study
was carried out in accordance with research quality standards for all
facets of the study including recruitment, data collection and storage.
Informed consent was sought from all study participants.
Due to the sensitive nature of the topic area the study lead was mindful
to ensure that appropriate measures were in place to support study
participants. This included information regarding local specialist services
should these be requested and the availability of the NS directly following
the training sessions and for follow-up meetings.
FINDINGS
Following analysis of the data three main themes emerged from the
interview data and these were:
Thinking outside of the box: The complexity of presentations of
abuse
Exploring the avenues: Practitioner-patient relationships
More likely to have the conversation: The DVA nurse specialist as
support
Thinking outside of the box: The complexity of presentations of
abuse
‘Thinking outside of the box’ is a term or metaphor that is often used in
general conversation to describe thinking differently about a problem or
issue. In the present study it was a term used by a number of interview
12
participants either directly as the following quote illustrates, or indirectly,
to describe the way in which the training sessions and/or the interactions
with the NS had provoked them to reflect on the ways in which they had
previously thought about DVA, for example their assumptions about the
presentation of abuse:
I think that when I went to the study day, it made me look more outside
that box. Because I think that people, when they think about abuse, you
think of all the different types of abuses, and it’s kind of a bit cut and dry,
where actually I actually think that that isn’t the case. I think there’s
quite, I was going to say quite a few, not quite a few, but there are
people who actually are controlled by other people, but they wouldn’t
class it as abuse (Participant 2)
The training sessions, which combined an introduction to the complexity
and breadth of possible presentations of DVA for example, using the
Duluth Model of Power and Control (DAIP, 2015) to explore issues of
psychological control, alongside anonymised case studies and a practical
demonstration of assessment tools, was highly valued by participants. Not
least because it provided participants with ‘time to think’ about how they
might approach DVA in their own practice and an opportunity to ask
questions, rather than the session having purely an ‘information giving’
focus:
I mean she was brilliant [the NS], she was really good. She did really
make you think, you know…I think really because, I think as nurses you
13
have so much training about different things that you’ve never allowed
yourself that amount of time to sit and think about that. So it allowed
you to do that…
Participant 3
Now having had the training with [NS] I now know what to look for, the
very subtle controlling behaviour, and I wasn’t so good at picking that up
before. But luckily having done the training with her almost from day one
I thought oh all those things that she talked about, all those subtle
controlling things I could see in this family (Participant 6)
The focus of the training sessions towards the complexity of possible
presentations of DVA in everyday practice also enabled practitioners to
reflect on their own areas of work. As the following participant
highlighted, while she had thought she was quite knowledgeable about
DVA, she hadn’t been aware of a significant issue with regard to her own
area of practice:
I thought it was really good […] going through the different types of
domestic violence as well, things that maybe you wouldn’t immediately
have raised concerns. And I kind of went into that training thinking that I
was pretty informed about domestic violence really […] but she talked a lot
about recognising about pregnancy being a very vulnerable time for people.
And I hadn’t realised that pregnancy alone was a factor for increasing risk
of domestic violence. So that was quite enlightening to me to say that I
14
work in an early pregnancy unit and I hadn’t been aware that that
automatically increased the rate of domestic violence (Participant 5)
It was also highlighted that practitioners both valued the training in terms
of raising awareness about the role of the NS and in terms of developing
their skills and knowledge base more generally with regard to DVA:
It was brilliant, because basically we were asking for information about a
service we didn’t know about [before the session] but knew that we could
use and tap into (Participant 11)
[NS education was] very insightful because you wouldn’t get that training,
unless you’ve been subjected to it yourself you would never know what
domestic violence is like or what to look out for as a healthcare
professional… (Participant 10)
Exploring the avenues: Practitioner-patient relationships
Contemporary nursing practice is widely acknowledged for the most part
as ‘fast paced’ with little time available to spend ‘talking’ with patients. In
the present study for example, Participant 4 reflected on her prior
experience of working in the ED, an area which has received considerable
attention as a key location for disclosure of DVA. She then contrasted this
to her experience of working in an in-patient environment and the time
constraints of the ED:
15
If you’re working in ED and you then get someone and they start
divulging lots of information to you, you can’t just say sorry I can’t talk to
you. So in the back of your mind, although it shouldn’t be, you are
thinking I’ve got to get to the next patient. So I don’t know whether
sometimes ED is the best place to have these long conversations
(Participant 4)
While the ED is undoubtedly a key location for the identification and
management of DVA, the present study clearly highlighted that other
clinical settings were ideally suited to providing the privacy and ‘time’ for
disclosure, for example as the following participant described the process
of the clinical assessment and the opportunity this provided for one-to-
one discussion:
…although we spend the first part of the consultation doing the clinical
assessment, that only usually takes about 10 minutes. So you’ve got 20
minutes to actually explore the avenues that the patients want to explore
really. And it does give you time, and it gives you an insight into the
family. And sometimes people will leave their family outside, because
they want to have that time to discuss things on their own (Participant
2)
Participants felt that being a nurse or practitioner placed them in a
position of ‘trust’ generally where people ‘tell you things’. However, more
particularly for participants both the longevity of patient relationships
within particular care settings and/or the length of stay in hospital
16
provided the potential to build relationships of trust and to provide a ‘safe’
environment for disclosure:
Well we’ve literally got a lady on the ward now actually who we’ve
referred to [NS] she has come in with […] excessive nausea in pregnancy.
She’s eight weeks pregnant and she’s [just] disclosed that her partner’s
been quite verbally abusive towards her… (Participant 5)
So it’s taken me seven weeks getting to know this mum…and this week
she has disclosed to me that there has been domestic violence for a very
long time and controlling behaviour (Participant 6)
…there was just little hints and drip feeding almost information each week.
And then that information put together lent to a private conversation with
her. It transpired that she’d been in quite an abusive relationship
(Participant 11)
In addition to the physical proximity of the nurse-patient relationship as
described above, in the present study it was also acknowledged that the
complexity of the illness or presenting condition might also be bound up in
with underlying issues, including DVA:
[The] pain is a manifestation of an earlier source of distress that comes
out in a physical way if you like. So the pain is almost like part of the
problem, but all the other stuff needs addressing as well. [The training was]
very useful, very useful in terms of people who disclose abuse. And it’s
having a mechanism for us to be able to seek support to help people with
that (Participant 11)
17
More likely to have the conversation: The DVA nurse specialist as
support
All of the participants in the study spoke of how the NS role, both the
training and on-going support had been invaluable in enabling them to
speak to patients where DVA was disclosed or suspected. Participants
also clearly recognised the importance of their role in terms of being a
key point of contact for disclosure or identification of DVA.
However, several participants also described how they ‘didn’t know’ how
to initiate a conversation about DVA with patients, even when they were
experienced practitioners:
And the first time I had to do that I didn’t know how to do it, which is silly
because I’m nearly 50 years old. I’ve got 30 years nursing background,
but you’re not trained or used to having those conversations. So having
the training from [NS] was invaluable for my role, and it empowers you and
it makes you much more likely to have the conversation. Because it’s very
easy not to have the conversation, because then the problem doesn’t
appear, you don’t have to solve it (Participant 6)
Moreover, as the following participant identified, while seeking the advice
of the NS gave her ‘confidence’ to ask about DVA, ‘probing’ into very
personal aspects of someone’s life did not feel as though it was part of
her professional role:
18
I rang [NS] and she told me what to do. And that, well I say it gave me
the confidence to go and talk to the lady about it, but it was still horrible.
Being the first time you’ve ever done something like that. It’s like you’re
being really personal and probing into somebody’s life when you’ve never
done that before, and that doesn’t feel like my role (Participant 9)
While asking questions about DVA could be difficult, it was also
acknowledged that practitioners were in a position where they might have
‘a feeling’ that DVA might be occurring. Therefore it was important to put
aside feelings of personal discomfort:
I took a phone call from one of her friends…It wasn’t anything she said
[outright] but I thought I wonder if this person is the victim of domestic
abuse. And I just said to her I need to ask you a question now, but it’s for
your safety that I do ask. I didn’t skirt around and I just literally came
out with the sentence, are you the victim of domestic abuse? And she
just broke down in tears and cried and said yes (Participant 8)
…but I think that’s one thing that she did reiterate [the NS in the sessions]
is ‘ask the question’, and the worst they can say is no (Participant 5)
Furthermore, the training and continued support of the NS was invaluable
both in terms of the development of professional confidence to approach
DVA with patients and also in terms of facilitating senior practitioners in
supporting members of the nursing team themselves:
So I wouldn’t expect them [members of the team] to deal with a
situation, but I would expect them to bring something to my attention.
19
That when they’re doing their weights and their blood pressure, if they
notice that there’s bruising when their arm thing up and they try to cover
it up, or even if it’s just a gut feeling (Participant 2)
A senior member of neonatal care team also described how she
approached the NS after she had identified DVA within her clinical
practice. She also acknowledged the way in which the NS instilled
confidence to ask about DVA but also how this initial experience has
significantly informed her ongoing practice:
I hadn’t got a clue where to go with it, and I went to [NS] to take advice
and she was just brilliant. Not only is she incredibly good at what she
does, she doesn’t dramatise anything. She’s very accessible…So from the
probably four families that I’ve taken advice for, although that probably
doesn’t seem much over the year, they are four of the most vulnerable
babies and mothers that I can think of (Participant 6)
DISCUSSION
As previously described, within the existing DVA literature the main focus
for DVA interventions and on-going support has been towards a limited
number of defined areas of healthcare provision (Ellsberg, et al. 2015).
However, the findings of this study have highlighted that the presentation
of DVA is a significant concern for practitioners across a wide range of
hospital based care services. It was also clear that the organisation of the
NS role, situated in this instance within the wider safeguarding, ED and
20
midwifery DVA teams within the Trust, facilitated a more cohesive
approach to management at an organisational level beyond the ED. This
was central to the facilitation of effective identification and management
of DVA, for example where patients might not be physically well enough
to respond to questioning in the ED, where privacy and the opportunity to
speak to the patient alone might be deemed problematic or where there
were overlaps between safeguarding concerns and DVA. Moreover, as van
de Wath et al. (2013) have highlighted, the building of rapport or trust, as
illustrated in the present study through the longevity of the presenting
condition, is highly valued by survivors of abuse (Watt, et al. 2008) and
may facilitate disclosure.
The delivery of training to practitioners within the Trust was a central part
of the NS role at inception and the format of the training included detailed
theory around DVA and practice development. However, early on in the
study it became apparent that, due to time constraints, the training would
need to be streamlined from the original format. McCloskey et al. (2005)
have highlighted elsewhere that the content of training is more important
than the length of the training itself. However, there are core elements
that need to be included. It has been recognised that alongside practical
information, for example how to respond to disclosure, the completion of
risk assessment and referral, training also needs to include a
consideration of the theory and complexity of DVA in terms of cohesive
control (DAIP, 2015). The importance of the theoretical component of
training has been highlighted by Westmorland et al. (2004) in terms of
21
enabling practitioners to “[broaden] the way they viewed domestic
violence, with a move away from a narrow emphasis on physical violence”
(Westmorland, et al. 2004, p17). In the present study therefore this
combined model was retained for training, albeit in a slightly shorter
format.
The findings from the present study have highlighted the value of the
training sessions overall both in terms of practical advice alongside ‘time
to reflect’ and exploration of the often complex or ‘hidden’ nature of
abuse. However, the tensions in terms of time allocated for practitioners
to attend the sessions cannot be ignored and, as the training sessions
were not mandatory also raises wider questions with regard to how DVA
training could or should be embedded more widely across organisations to
form a part of core professional preparation and development for
practitioners (NICE, 2014).
In addition to the educational component of the training, the sessions also
provided an opportunity for the NS to raise awareness among
practitioners about the nature and scope of her role within the Trust. The
findings of the present study have highlighted the value that practitioners
placed on the NS as a source of information generally. More importantly,
the study has also highlighted the centrality of the NS as a pivotal point of
contact for direct ‘on the spot’ guidance and supporting professional
confidence among practitioners. This was evident for example, in terms of
the complexity of presentations, discomfiture and stigma associated with
22
asking about ‘personal or private issues’ or a fear of offending patients by
asking about DVA. It may therefore be argued as elsewhere (Yam, 2000)
that awareness raising and training is not in itself sufficient and that there
is a clear need for an identified individual within an organisation with the
requisite skills and expertise to support clinical staff in effective
recognition and management of DVA (author, 2015). In a similar vein,
Leppakoshi et al. (2014) have also considered the potential for a ‘mentor’
or ‘role model’ as an effective part of clinical staff support.
Finally, it has been identified that DVA can be an emotional and ‘painful’
subject on a personal level for clinical staff (O’Malley, et al. 2013) and in
the present study an unintended consequence was the disclosure of DVA
among staff, particularly following the training sessions. As a result, the
NS has also worked with the Trust to develop clear mechanisms for staff
support. Similarly, a number of authors have also examined DVA
disclosure for clinical staff in terms of ‘emotional impact’ more generally
(van de wath, et al. 2012, Goldblatt, 2009). This arguably further
highlights that the needs of staff, in terms of the requisite organisational
structures and support, cannot be underestimated and form an integral
part of any planned intervention or model of care delivery.
LIMITATIONS
This was a small scale evaluative study and as such there needs to be
some caution exercised with regard to the claims that can be made in
terms of transferability. However, to the author’s knowledge this role
23
represents the first of its kind within acute hospital health care services.
As such the findings of this study offers a contribution to the growing
evidence base and broader debates with regard to effective identification,
management and support of DVA within healthcare contexts generally.
CONCLUSION
DVA continues to exert a significant and detrimental impact on the lives
and health of those who encounter abuse. Health care services globally
are increasingly on the frontline in terms of identification and
management of DVA. This is coupled with the growing recognition of the
need for adequate support and structures to be in place to facilitate
practitioners in providing effective care for survivors of DVA. This paper it
is hoped has contributed to the growing body of literature surrounding the
development of practice and the provision of effective support
mechanisms within the field of DVA.
RELEVANCE TO CLINICAL PRACTICE
To date there has been a limited consideration of how existing deficits in
the effective recognition and management might be addressed explicitly
within health care organisations. This study both explores the broader
clinical context of DVA presentations and provides a structured approach
of service delivery. This model has the potential to be explored further in
terms of applicability within similar health care settings.
24
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